Professor Pinki Sahota

BACKGROUND: Food insecurity has been associated with dietary intake and weight status in UK adults and children although results have been mixed and ethnicity has not been explored. We aimed to compare prevalence and trajectories of weight and dietary intakes among food secure and insecure White British and Pakistani-origin families. METHODS: At 12 months postpartum, mothers in the Born in Bradford cohort completed a questionnaire on food security status and a food frequency questionnaire (FFQ) assessing their child's intake in the previous month; at 18 months postpartum, mothers completed a short-form FFQ assessing dietary intake in the previous 12 months. Weights and heights of mothers and infants were assessed at 12-, 24-, and 36-months postpartum, with an additional measurement of children taken at 4-5 years. Associations between food security status and dietary intakes were assessed using Wilcoxon-Mann-Whitney for continuous variables and χ2 or Fisher's exact tests for categorical variables. Quantile and logistic regression were used to determine dietary intakes adjusting for mother's age. Linear mixed effects models were used to assess longitudinal changes in body mass index (BMI) in mothers and BMI z-scores in children. RESULTS: At 12 months postpartum, White British mothers reported more food insecurity than Pakistani-origin mothers (11% vs 7%; p < 0.01) and more food insecure mothers were overweight. Between 12 and 36 months postpartum, BMI increased more among food insecure Pakistani-origin mothers (β = 0.77 units, [95% Confidence Interval [CI]: 0.40, 1.10]) than food secure (β = 0.44 units, 95% CI: 0.33, 0.55). This was also found in Pakistani-origin children (BMI z-score: food insecure β = 0.40 units, 95% CI: 0.22, 0.59; food secure β = 0.25 units, 95% CI: 0.20, 0.29). No significant increases in BMI were observed for food secure or insecure White British mothers while BMI z-score increased by 0.17 (95% CI: 0.13, 0.21) for food secure White British children. Food insecure mothers and children had dietary intakes of poorer quality, with fewer vegetables and higher consumption of sugar-sweetened drinks. CONCLUSIONS: Food security status is associated with body weight and dietary intakes differentially by ethnicity. These are important considerations for developing targeted interventions.

Background: Worldwide, women fail to reach the recommended exclusive breastfeeding target of 6 months postpartum. The objective of this study was to present a conceptual and methodological synthesis of interventions designed to promote exclusive breastfeeding to 6 months in high-income countries. Materials and Methods: A systematic search of leading databases was conducted for scholarly peer-reviewed randomized trials published between January 2000 and June 2013. Seventeen articles were identified as relevant; all were published in English and assessed exclusive breastfeeding with a follow-up period extending beyond 4 months postpartum. Articles were analyzed for overall quality of evidence, regarding duration of exclusive breastfeeding, using the Grading and Recommendations Assessment, Development, and Evaluation approach. Results: A significant increase in the duration of exclusive breastfeeding was found in eight of the 17 studies, with most interventions using supportive or educational approaches. Interventions in pregnancy focused on educating mothers on the benefits of exclusive breastfeeding. Fifteen interventions took place, at least in part, in the postnatal period and provided educational and emotional support to mothers. Of the eight successful interventions, five took part in the postnatal period in the mothers' own homes. The quality of the evidence for duration of exclusive breastfeeding was moderate. Conclusions: The most successful interventions were conducted in the postnatal period and over a long period of time; however, the findings were inconsistent. No study assessed intervention fidelity, and only two studies noted maternal body mass index, a variable known to affect exclusive breastfeeding rates. Further research is needed to provide a robust evidence base to inform future interventions. © Mary Ann Liebert, Inc.

Poor participant engagement threatens the potential impact and cost-effectiveness of public health programmes preventing meaningful evaluation and wider application. Although barriers and levers to engagement with public health programmes are well documented, there is a lack of proven strategies in the literature addressing these. This paper details the development of a participant engagement intervention aimed at promoting enrolment and attendance to a community-based pre-school obesity prevention programme delivered in UK children's centres; HENRY (Health, Exercise, Nutrition for the Really Young). The Behaviour Change Wheel framework was used to guide the development of the intervention. The findings of a coinciding focused ethnography study identified barriers and levers to engagement with HENRY that informed which behaviours should be targeted within the intervention to promote engagement. A COM-B behavioural analysis was undertaken to identify whether capability, opportunity or motivation would need to be influenced for the target behaviours to occur. APEASE criteria were used to agree on appropriate intervention functions and behaviour change techniques. A multi-level participant engagement intervention was developed to promote adoption of target behaviours that were proposed to promote engagement with HENRY, e.g. ensuring the programme is accurately portrayed when approaching individuals to attend and providing 'taster' sessions prior to each programme. At the local authority level, the intervention aimed to increase buy-in with HENRY to increase the level of resource dedicated to engagement efforts. At the centre level, managers were encouraged to widen promotion of the programme and ensure that staff promoted the programme accurately. HENRY facilitators received training to increase engagement during sessions, and parents that had attended HENRY were encouraged to recruit their peers. This paper describes one of the first attempts to develop a theory-based multi-level participant engagement intervention specifically designed to promote recruitment and retention to a community-based obesity prevention programme. Given the challenges to implementing public health programmes with sufficient reach, the process used to develop the intervention serves as an example of how programmes that are already widely commissioned could be optimised to enable greater impact.

Background: Children's centres in the UK provide a setting for public health programmes; offering support to families living in the most disadvantaged areas where obesity prevalence is at its highest. Health, Exercise and Nutrition in the Really Young (HENRY) is an eight-week obesity prevention programme currently delivered in children's centres across the UK. However, low participant engagement in some local authorities threatens its potential reach and impact. This study aimed to explore the factors influencing participant engagement with HENRY to describe where local intervention may support engagement efforts. Method: A focused ethnography study was undertaken in five children's centres delivering HENRY across the UK. One hundred and ninety hours of field observations, 22 interviews with staff (commissioners, HENRY co-ordinators, managers and facilitators) and six focus groups (36 parents), took place over five consecutive days in each centre. The Consolidated Framework for Implementation Research (CFIR) was used to guide the observations and analysis of the data. Results: Three overarching themes described the factors influencing participant engagement with HENRY: local authority decision making around children's centre programmes; children's centre implementation of HENRY; and the participant experience of HENRY. The results indicate that factors influencing participant engagement with public health programmes begin at the commissioning body level, influencing children's centre implementation and subsequently the experience of participants. Local authority funding priorities and constraints influence availability of places and who these places are offered to, with funding often targeted towards those deemed most at need. This was perceived to have a detrimental effect on participant experience of the programme. Conclusion: In summary, participant engagement is affected by multiple factors, working at different levels of the children's centre and local authority hierarchy, most of which are at play even before participants decide whether or not they choose to enrol and maintain attendance. For programmes to achieve their optimal reach and impact, factors at the commissioning and local implementation level need to be addressed prior to addressing participant facing issues.

Objective and method: The present study followed a group of 608 children, aged 7-11 years from six primary schools, for whom detailed dietary information was available. These children were traced four years later when they were in secondary school. The aim of the study was to investigate the relationship between the original dietary pattern, current dietary pattern, toothbrushing habit and oral health. Of the original children, 500 were traced to 32 secondary schools over a wide geographic area. For logistical reasons those in 18 schools were selected and positive consent and full data was obtained for 315 together with an additional group of 122 of their classmates. Three-day, self-reported dietary data was obtained, together with information on toothbrushing habits. A dental examination was carried out using BASCD survey methodology. Results: The children in this study had a lower DMFT (0.82) than found in the most recent survey for the area (1.39). No significant relationship was found between sugar-sweetened foods or drinks at age 7-11 and caries in the first permanent molar teeth at age 11-15 years, however a significant relationship was found between current sugar-sweetened drinks consumption and caries. Significantly less caries was associated with the reported moderate consumption of dairy products by the children when aged 1115 years. The bedtime consumption of NMES drinks at 7-11 was significantly associated with an increase in caries as was the bedtime consumption of non-milk extrinsic sugars (NMES) foods at 11-15 years. A significant inverse relationship was found between claimed toothbrushing frequency and caries. Of those children aged 11-15 years claiming to brush at least once a day, 69% were caries-free with a mean DMFT of 0.69. Of the children who claimed to brush only occasionally or never, 52% were caries-free and they had a mean DMFT of 1.05. Conclusion: The reported consumption of sugar-sweetened drinks and the lack of regular toothbrushing were found to be the factors most strongly linked to caries and this finding is consistent with other recent studies. © BASCD 2007.

OBJECTIVE: Knowledge of the types and quantities of foods and drinks available in family homes supports the development of targeted intervention programmes for obesity prevention or management, or for overall diet improvement. In the UK, contemporary data on foods that are available within family homes are lacking. The present study aimed to explore home food and drink availability in UK homes. DESIGN: An exploratory study using researcher-conducted home food availability inventories, measuring all foods and drinks within the categories of fruits, vegetables, snack foods and beverages. SETTING: Bradford, a town in the north of the UK. SUBJECTS: Opportunistic sample of mixed ethnicity families with infants approximately 18 months old from the Born in Bradford birth cohort. RESULTS: All homes had at least one type of fruit, vegetable and snack available. Fresh fruits commonly available were oranges, bananas, apples, satsumas and grapes. Commonly available fresh vegetables included potatoes, cucumber, tomatoes and carrots. The single greatest non-fresh fruit available in homes was raisins. Non-fresh vegetables contributing the most were frozen mixed vegetables, tinned tomatoes and tinned peas. Ethnic differences were found for the availability of fresh fruits and sugar-sweetened beverages, which were both found in higher amounts in Pakistani homes compared with White homes. CONCLUSIONS: These data contribute to international data on availability and provide an insight into food availability within family homes in the UK. They have also supported a needs assessment of the development of a culturally specific obesity prevention intervention in which fruits and vegetables and sugar-sweetened beverages are targeted.

OBJECTIVE: To compare the intake of key indicator foods at age 12 months and 18 months between infants of Pakistani and White British origin. DESIGN: Logistic regression was used to model associations between ethnicity and consumption of key indicator foods defined by high or low energy density using an FFQ at age 12 and 18 months. SETTING: Born in Bradford 1000 study, Bradford, UK. SUBJECTS: Infants (n 1259; 38 % White British, 49 % Pakistani), mean age 12·7 (sd 1·0) months and toddlers (n 1257; 37 % White British, 49 % Pakistani), mean age 18·7 (sd1·0) months. RESULTS: At 12 months, Pakistani infants consumed more commercial sweet baby meals than White British infants, with greater odds for being above average consumers (adjusted OR (AOR)=1·90; 95 % CI 1·40, 2·56), more chips/roast potatoes (AOR=2·75; 95 % CI 2·09, 3·62), less processed meat products (AOR=0·11; 95 % CI 0·08, 0·15), more fruit (AOR=2·20; 95 % CI 1·70, 2·85) and more sugar-sweetened drinks (AOR=1·68; 95 % CI 1·29, 2·18). At 18 months these differences persisted, with Pakistani infants consuming more commercial sweet baby meals (AOR=4·57; 95 % CI 2·49, 8·39), more chips/roast potato shapes (AOR=2·26; 95 % CI 1·50, 3·43), more fruit (AOR=1·40; 95 % CI 1·08, 1·81), more sugar-sweetened drinks (AOR=2·03; 95 % CI 1·53, 2·70), more pure fruit juice (AOR=1·82; 95 % CI 1·40, 2·35), more water (AOR=3·24; 95 % CI 2·46, 4·25) and less processed meat (AOR=0·10; 95 % CI 0·06, 0·15) than White British infants. CONCLUSIONS: Dietary intake during infancy and the early toddlerhood period is associated with ethnicity, suggesting the importance of early and culturally adapted interventions aimed at establishing healthy eating behaviours.

Many interventions that are delivered within public health services have little evidence of effect. Evaluating interventions that are being delivered as a part of usual practice offers opportunities to improve the evidence base of public health. However, such evaluation is challenging and requires the integration of research into system-wide practice. The Born in Bradford's Better Start experimental birth cohort offers an opportunity to efficiently evaluate multiple complex community interventions to improve the health, wellbeing and development of children aged 0-3 years. Based on the learning from this programme, this paper offers a pragmatic and practical guide to researchers, public health commissioners and service providers to enable them to integrate research into their everyday practice, thus enabling relevant and robust evaluations within a complex and changing system.Using the principles of co-production the key challenges of integrating research and practice were identified, and appropriate strategies to overcome these, developed across five key stages: 1) Community and stakeholder engagement; 2) Intervention design; 3) Optimising routinely collected data; 4) Monitoring implementation; and 5) Evaluation. As a result of our learning we have developed comprehensive toolkits ( https://borninbradford.nhs.uk/what-we-do/pregnancy-early-years/toolkit/ ) including: an operational guide through the service design process; an implementation and monitoring guide; and an evaluation framework. The evaluation framework incorporates implementation evaluations to enable understanding of intervention performance in practice, and quasi experimental approaches to infer causal effects in a timely manner. We also offer strategies to harness routinely collected data to enhance the efficiency and affordability of evaluations that are directly relevant to policy and practice.These strategies and tools will help researchers, commissioners and service providers to work together to evaluate interventions delivered in real-life settings. More importantly, however, we hope that they will support the development of a connected system that empowers practitioners and commissioners to embed innovation and improvement into their own practice, thus enabling them to learn, evaluate and improve their own services.

This lecture examined the lifestyle factors that contribute to the development of obesity; namely diet and physical activity and questioned why, despite being aware of these modifiable risk factors, it is such a challenge to reverse the trends in the increasing prevalence of childhood obesity. It considered the challenges for practitioners, researchers and policy-makers and then drew on the experience from the development, delivery and evaluation of a number of childhood obesity prevention programmes to make recommendations for future interventions. The solutions are far from straightforward for a condition which on the surface appears simple and this lecture aims to begin the debate about the kind of measures that should or could be considered. However there is consensus that a co-ordinated approach is essential across government departments that links with food industry, media, local government and public health departments, health and social services, local communities, parents and carers to ensure that healthier choices are the easier choices in our everyday lives. The lecture concluded by highlighting future directions for research that involve the experience of users, practitioners and researchers in order to develop, deliver and evaluate interventions to address this major public health issue.

Epidemiological evidence indicates that early life factors are important for obesity development but there are gaps in knowledge regarding the impact of exposures during pregnancy and early life, especially in South Asian children. There is a corresponding lack of evidence to guide development of culturally-appropriate, obesity prevention programmes. This paper describes the methodology and characteristics of participants in Born in Bradford 1000 (BiB1000), a nested cohort of the Born in Bradford prospective birth cohort. BiB1000 aims to enable a deep and extensive understanding of the predictors and influences of health-related behaviours to develop a culturally-specific obesity prevention intervention. 1,735 mothers agreed to take part in detailed assessments focused on risk factors of obesity. Of these, 1,707 had singleton births. Data were collected from the families during pregnancy, at birth and when the infant was aged 6, 12, 18, 24 and 36 months. Approximately half of the mothers (n=933) are of South Asian ethnicity; of which, just under half were born in the UK. Prevalence of obesity in BiB1000 is similar to the full BiB cohort and to UK national averages. In addition to pre-specified hypothesised targets for obesity prevention, (e.g. parental feeding styles, diet and activity), BiB1000 is exploring qualitative determinants of behaviours andother exposures with a lesser evidence base (e.g. food environments, sleep, parenting practices). These data will enable a rich understanding of the behaviours and their determinants in order to inform the development of a culturally-relevant, childhood obesity prevention intervention.

BACKGROUND: Early interventions are recognised as key to improving life chances for children and reducing inequalities in health and well-being, however there is a paucity of high quality research into the effectiveness of interventions to address childhood health and development outcomes. Planning and implementing standalone RCTs for multiple, individual interventions would be slow, cumbersome and expensive. This paper describes the protocol for an innovative experimental birth cohort: Born in Bradford's Better Start (BiBBS) that will simultaneously evaluate the impact of multiple early life interventions using efficient study designs. Better Start Bradford (BSB) has been allocated £49 million from the Big Lottery Fund to implement 22 interventions to improve outcomes for children aged 0-3 in three key areas: social and emotional development; communication and language development; and nutrition and obesity. The interventions will be implemented in three deprived and ethnically diverse inner city areas of Bradford. METHOD: The BiBBS study aims to recruit 5000 babies, their mothers and their mothers' partners over 5 years from January 2016-December 2020. Demographic and socioeconomic information, physical and mental health, lifestyle factors and biological samples will be collected during pregnancy. Parents and children will be linked to their routine health and local authority (including education) data throughout the children's lives. Their participation in BSB interventions will also be tracked. BiBBS will test interventions using the Trials within Cohorts (TwiCs) approach and other quasi-experimental designs where TwiCs are neither feasible nor ethical, to evaluate these early life interventions. The effects of single interventions, and the cumulative effects of stacked (multiple) interventions on health and social outcomes during the critical early years will be measured. DISCUSSION: The focus of the BiBBS cohort is on intervention impact rather than observation. As far as we are aware BiBBS is the world's first such experimental birth cohort study. While some risk factors for adverse health and social outcomes are increasingly well described, the solutions to tackling them remain elusive. The novel design of BiBBS can contribute much needed evidence to inform policy makers and practitioners about effective approaches to improve health and well-being for future generations.

BACKGROUND: Many modifiable risk factors in early infancy have been shown to be associated with childhood overweight and obesity. These risk factors have not been studied within children of South Asian origin in the UK. The aims of this paper are to describe differences in the prevalence of modifiable risk factors for childhood obesity between children of White British and Pakistani origin and investigate the association between these risk factors and childhood BMI measured at age 3 years. We used data from a sub-study of the Born in Bradford birth cohort with detailed follow-up visits throughout early childhood. 987 participants with a BMI measurement at age 3 were included; 39% were White British, 48% were of Pakistani origin and 13% were of other ethnicities. Linear and Poisson regression models were used to assess the association between risk factors and two outcomes at age 3; BMI z-scores and child overweight. RESULTS: Compared to Pakistani mothers, White British mothers were more likely to smoke during pregnancy, have higher BMI, breastfeed for a shorter duration and wean earlier, while Pakistani mothers had higher rates of gestational diabetes and were less active. There was no strong evidence that the relationship between risk factors and BMI z-score differed by ethnicity. There were associations between BMI z-score and maternal smoking (mean difference in BMI z-score 0.33 (95% CI 0.13, 0.53)), maternal obesity (0.37 (0.19, 0.55)), indulgent feeding style (0.15 (-0.06, 0.36)), lower parental warmth scores (0.21 (0.05, 0.36)) and higher parental hostility scores (0.17 (0.01, 0.33)). Consistent associations between these risk factors and child overweight were found. Mean BMI and the relative risk of being overweight were lower in children of mothers with lower parental self-efficacy scores and who watched more hours of TV. Other risk factors (gestational diabetes, child diet, child sleep, child TV viewing and maternal physical activity) were not associated with BMI. CONCLUSIONS: Whilst the prevalence of risk factors that have been associated with childhood greater BMI differ between White British and Pakistani the magnitude of their associations with BMI are similar in the two groups.

The present study aimed to explore previously unreported ethnic differences in infant feeding practices during the introduction of solid foods, accounting for maternal and birth factors, and to determine whether these feeding patterns are associated with BMI at 3 years of age. An observational study using Poisson regression was carried out to investigate the relationship between ethnicity and infant feeding practices and linear regression was used to investigate the relationship between feeding practices and BMI at 3 years of age in a subsample of 1327 infants in Bradford. It was found that compared with White British mothers, mothers of Other ethnicities were less likely to replace breast milk with formula milk before introducing solid foods (adjusted relative risk (RR) - Pakistani: 0·76 (95 % CI 0·64, 0·91), Other South Asian: 0·58 (95 % CI 0·39, 0·86), and Other ethnicities: 0·50 (95 % CI 0·34, 0·73)). Pakistani and Other South Asian mothers were less likely to introduce solid foods early ( < 17 weeks) (adjusted RR - Pakistani: 0·92 (95 % CI 0·87, 0·96) and Other South Asian: 0·87 (95 % CI 0·81, 0·93)). Other South Asian mothers and mothers of Other ethnicities were more likely to continue breast-feeding after introducing solid foods (adjusted RR - 1·72 (95 % CI 1·29, 2·29) and 2·12 (95 % CI 1·60, 2·81), respectively). Pakistani and Other South Asian infants were more likely to be fed sweetened foods (adjusted RR - 1·18 (95 % CI 1·13, 1·23) and 1·19 (95 % CI 1·10, 1·28), respectively) and Pakistani infants were more likely to consume sweetened drinks (adjusted RR 1·72 (95 % CI 1·15, 2·57)). No association between infant feeding practices and BMI at 3 years was observed. Although ethnic differences in infant feeding practices were found, there was no association with BMI at 3 years of age. Interventions targeting infant feeding practices need to consider ethnicity to identify which populations are failing to follow recommendations.

INTRODUCTION: Interventions that make extensive use of theory tend to have larger effects on behaviour. The Intervention Mapping (IM) framework incorporates theory into intervention design, implementation and evaluation, and was applied to the development of a community-based childhood obesity prevention intervention for a multi-ethnic population. METHODS: IM was applied as follows: 1) Needs assessment of the community and culture; consideration of evidence-base, policy and practice; 2) Identification of desired outcomes and change objectives following identification of barriers to behaviour change mapped alongside psychological determinants (e.g. knowledge, self-efficacy, intention); 3) Selection of theory-based methods and practical applications to address barriers to behaviour change (e.g., strategies for responsive feeding); 4) Design of the intervention by developing evidence-based interactive activities and resources (e.g., visual aids to show babies stomach size). The activities were integrated into an existing parenting programme; 5) Adoption and implementation: parenting practitioners were trained by healthcare professionals to deliver the programme within Children Centres. RESULTS: HAPPY (Healthy and Active Parenting Programme for Early Years) is aimed at overweight and obese pregnant women (BMI > 25); consists of 12 × 2.5 hr. sessions (6 ante-natal from 24 weeks; 6 postnatal up to 9 months); it addresses mother's diet and physical activity, breast or bottle feeding, infant diet and parental feeding practices, and infant physical activity. CONCLUSION: We have demonstrated that IM is a feasible and helpful method for providing an evidence based and theoretical structure to a complex health behaviour change intervention. The next stage will be to assess the impact of the intervention on behaviour change and clinical factors associated with childhood obesity. The HAPPY programme is currently being tested as part of a randomised controlled feasibility trial.

Copyright © The Authors 2018 Objective: To assess relationships between dietary intake at age 12, 18 and 36 months and BMI Z-scores at age 36 months in a bi-ethnic group. Design: A prospective cohort study comparing cross-sectional and longitudinal data. Exposures included dietary intake at 12, 18 and 36 months (FFQ) with an outcome of BMI Z-score at age 36 months. Setting: Born in Bradford 1000 study, Bradford, UK. Subjects: Infants at age 12 months (n 722; 44 % White British, 56 % Pakistani), 18 months (n 779; 44 % White British, 56 % Pakistani) and 36 months (n 845; 45 % White British, 55 % Pakistani). Results: Diet at age 12 months was not associated with BMI Z-score at age 36 months. Higher consumption of vegetables at 18 and 36 months was associated with a lower BMI Z-score at 36 months (model coefficient (95 % CI): −0·20 (−0·36, −0·03) and −0·16 (−0·31, −0·02), respectively). Higher consumption of high-fat chips at age 36 months was associated with a lower BMI Z-score at age 36 months (−0·16 (−0·32, 0·00)). Overall, White British children had higher 36-month BMI Z-scores than Pakistani children (adjusted mean difference (95 % CI): 0·21 (0·02, 0·41)). Conclusions: Our findings indicate that dietary intake at 18 and 36 months was somewhat related to BMI Z-score at age 36 months and suggest the importance of early interventions aimed at establishing healthy eating behaviours.

This chapter examines current evidence-base and highlights effective strategies and interventions for parents and carers with the home and early years' settings for the prevention of childhood obesity. It presents key messages related to establishing healthy diet, physical activity and sedentary behaviours. An example of a government initiative from an international perspective is presented as an illustration of good practice. Parents and carers should be encouraged to follow responsive feeding practices by allowing children to determine how much they eat which in turn will reinforce internal cues for hunger and satiety and consequently result in self-regulation of energy intake. To prevent the development of overweight and obesity in their child, parents and carers should consider some specific aspects in relation to energy intake. Meal and snack times should be spaced at regular intervals throughout the day in order to prevent feelings of excess hunger and tendency to overeat.

Despite interest in the importance of the home food environment and its potential influence on children's diets and social norms, there remain few self-report checklist methods that have been validated against the gold standard of researcher-conducted inventories. This study aimed to assess the criterion validity and reliability of the 'Home Food Availability Inventory Checklist' (HFAI-C), a 39-item checklist including categories of fruit, vegetables, snacks and drinks.The HFAI-C was completed by 97 participants of White and Pakistani origin in the UK. Validity was determined by comparing participant-reported HFAI-C responses to data from researcher observations of home food availability using PABAK and weighted kappa statistics. The validity of measuring the amount of items (in addition to presence/absence) available was also determined. Test-retest reliability compared repeated administrations of the HFAI-C using intra-class correlation coefficients.Validity and reliability was fair to moderate overall. For validity, the average category-level PABAK ranged from 0.31 (95 % CI: 0.25, 0.37) for vegetables to 0.44 (95 % CI: 0.40, 0.49) for fruits. Assessment of the presence/absence of items demonstrated higher validity compared to quantity measurements. Reliability was increased when the HFAI-C was repeated close to the time of the first administration. For example, ICCs for reliability of the measurement of fruits were 0.52 (95 %CI: 0.47, 0.56) if re-administered within 5 months, 0.58 (95 % CI: 0.51, 0.64) within 30 days and 0.97 (95 %CI: 0.94, 1.00) if re-administered on the same day.Overall, the HFAI-C demonstrated fair to moderate validity and reliability in a population of White and South Asian participants. This evaluation is consistent with previous work on other checklists in less diverse, more affluent populations. Our research supports the use of the HFAI-C as a useful, albeit imperfect, representation of researcher-conducted inventories. The feasibility of collecting information using the HFAI-C in large, multi-ethnic samples can facilitate examination of home food availability in relation to exposures such as ethnicity and outcomes including behavioural, social and health outcomes. Future work using the HFAI-C could provide important insights into a modifiable influence with potential to impact health.

Presents results of focus group discussions held with 300 nine‐to‐11‐year old UK children. Questions were asked about whether it matters if someone is fat or thin; whether a fat child should take any action; what problems they might have; and the relationship between fatness, thinness and health. Considerable complexity emerged; children divided fat children into those for whom it was natural and those for whom it was self‐inflicted. They showed a great deal of sympathy for “naturally” fat children. However, they also felt that fat children would be bullied. Girls seemed less able than boys to resist the pressures to be thin, but also showed considerable ability to distance themselves from media images of thin women. Although children had learned the orthodoxy surrounding health, fat and overweight, they did not believe that “thin is good, fat is bad” and did not tend to link weight control with exercise.

OBJECTIVES: To implement a school based health promotion programme aimed at reducing risk factors for obesity and to evaluate the implementation process and its effect on the school. DESIGN: Data from 10 schools participating in a group randomised controlled crossover trial were pooled and analysed. SETTING: 10 primary schools in Leeds. PARTICIPANTS: 634 children (350 boys and 284 girls) aged 7-11 years. MAIN OUTCOME MEASURES: Response rates to questionnaires, teachers' evaluation of training and input, success of school action plans, content of school meals, and children's knowledge of healthy living and self reported behaviour. RESULTS: All 10 schools participated throughout the study. 76 (89%) of the action points determined by schools in their school action plans were achieved, along with positive changes in school meals. A high level of support for nutrition education and promotion of physical activity was expressed by both teachers and parents. 410 (64%) parents responded to the questionnaire concerning changes they would like to see implemented in school. 19 out of 20 teachers attended the training, and all reported satisfaction with the training, resources, and support. Intervention children showed a higher score for knowledge, attitudes, and self reported behaviour for healthy eating and physical activity. CONCLUSION: This programme was successfully implemented and produced changes at school level that tackled risk factors for obesity.

A plant-based diet, with an emphasis on plant foods and limited amounts of refined processed foods and animal products, conveys substantial health benefits. The objective of this study was to explore adolescents' attitudes and perceptions towards plant-based foods, both in and out of the school environment. Semi-structured focus group interviews were conducted with Year 10 students (age 14-15 years) (n=29) attending a large secondary school in the city of Leeds, UK. The focus group interviews were audio recorded, transcribed verbatim, and categories and concepts were derived using a grounded theory methodology. Emergent theories were tested against the data collected and existing theories, until the final categories and concepts, as well as their interrelationships were well defined. Data analysis provided four main categories (Food choice parameters; Perceived drivers and benefits of plant-based foods; Environmental food cues; Barriers to plant-based food choice) each with their related concepts. The disconnect between plant-based foods and adolescents' food choice parameters is highlighted, and barriers to adolescents adopting a plant-based diet are differentiated and considered with respect to practice and policy. Opportunities to remodel and re-present plant-based foods in order to shift adolescents' diets are explored. The grounded theory that emerged focuses on the disconnect between adolescents' food choice parameters and plant-based foods. The study suggests implications for practice and policy with opportunities to improve and manage adolescents' diet.

With growing evidence for the health benefits of a plant-based diet, and adolescents' diets typically marked by poor food choices, this study's objective was to evaluate the impact of changes to the choice architecture within a secondary school canteen on students' plant-based food choices. A set of small changes to nudge students towards specific food items (whole fruit, fruit salad, vegetarian main meals, sandwiches containing salad) was implemented for six weeks during the academic year 2013-14. Data (>200 000 transactions) from the cashless system employed in the school canteen enabled students' food choices (980 students) for the academic year (188 days) to be examined. Students' selections at baseline (29-week period), intervention (6-week period) and post-intervention (3-week period) were compared. Selection of the designated food items increased significantly during the intervention and post-intervention periods compared to baseline (baseline 1.2%; intervention 2.9%; post-intervention 2.2%) χ2(2)=328.18, p<0.001. Logistic regression analysis revealed the independent effect of the intervention on the uptake of these items. Controlling for student year group, free school meal entitlement (a measure of socioeconomic status), day of the week and price – students were 2.5 times more likely (p<0.001) to select the designated items during the intervention period, than at baseline. Small changes to the choice architecture nudged students towards more plant-based food choices. The results evidence the role schools and choice architecture can play in improving adolescents' dietary behavior.

Summary The aim of this project was to gain insight into children's understanding of healthy eating, and to explore the barriers and facilitating factors for dietary behaviour change in children. The ‘Apples’ project is concerned with obesity prevention, and an understanding of children's perceptions of healthy eating, fatness and thinness are vital in order for school‐based programmes to be appropriately designed and delivered. This paper presents data from focus groups with 300 children (aged 9–11 years) in 10 schools in Leeds, England, carried out in June 1998. Analysis of the transcripts shows that children understood the concept of a balanced diet as described by the Health Education Authority's ‘Balance of Good Health’ model. They were also aware of the relationship between their diet and health, both present and future. ‘Fat’ played a prominent role, with a healthy diet being one that did not contain too much fat. Moreover, they considered that it was fat that caused heart problems, the key consequence of not eating healthily. It was also important for social reasons not to be too fat, although children were also very aware of the health implications of being too thin, and of eating disorders. Children used a number of strategies to take control of their own eating, and the conclusions for nutrition education programmes in schools are that children need to be seen as more active participants in their own health education, and that help is needed to resist the pressures to be a socially desirable body weight.

OBJECTIVE: To assess if a school based intervention was effective in reducing risk factors for obesity. DESIGN: Group randomised controlled trial. SETTING: 10 primary schools in Leeds. PARTICIPANTS: 634 children aged 7-11 years. INTERVENTION: Teacher training, modification of school meals, and the development of school action plans targeting the curriculum, physical education, tuck shops, and playground activities. MAIN OUTCOME MEASURES: Body mass index, diet, physical activity, and psychological state. RESULTS: Vegetable consumption by 24 hour recall was higher in children in the intervention group than the control group (weighted mean difference 0.3 portions/day, 95% confidence interval 0.2 to 0.4), representing a difference equivalent to 50% of baseline consumption. Fruit consumption was lower in obese children in the intervention group (-1.0, -1.8 to -0.2) than those in the control group. The three day diary showed higher consumption of high sugar foods (0.8, 0.1 to 1.6)) among overweight children in the intervention group than the control group. Sedentary behaviour was higher in overweight children in the intervention group (0.3, 0.0 to 0.7). Global self worth was higher in obese children in the intervention group (0.3, 0.3 to 0.6). There was no difference in body mass index, other psychological measures, or dieting behaviour between the groups. Focus groups indicated higher levels of self reported behaviour change, understanding, and knowledge among children who had received the intervention. CONCLUSION: Although it was successful in producing changes at school level, the programme had little effect on children's behaviour other than a modest increase in consumption of vegetables.

Background:  Childhood obesity has significant impact on future health and economic consequences. Evidence of effectiveness of interventions is developing, although little is known about costs. Therefore, the direct costs to health care and other public sector agencies of a pilot community-based childhood obesity treatment programme were estimated. Methods:  The present study comprised a retrospective review of resource use of an intervention drawing resources from local government and primary care sectors and delivered across multiple settings. Ninety-six children, aged 8–16 years old; body mass index (BMI) >98th centile; mean BMI SD 3.1 and low quality of life scores attended a 12-month programme delivered by nonhealth professionals. Direct costs to health care and other public sector agencies were assessed. Results:  Total programme direct costs were £82 380 (€94 736, $123 569) in the base case or £120 474 (€138 546, $180 713) when venues were treated as real additional costs, and varied only slightly with the number of participants in the programme. Costs per participant were £858 (€987, $1287) in the base case or £1255 (€1443, $1883) when venues were treated as additional costs. Costs per participant were sensitive to the number of participants, varying between £691 (€795, $1037) and £2026 (€2330, $3039) when venue costs were zero and between £1009 (€1160, $1514) and £2978 (€3425, $4467) with venue costs added. Conclusions:  It is possible to provide a community-based service at reasonable cost, and probably less than for health professional delivered services. Further work is required to assess the possible effects of the programme on wider service resource use, on users’ costs and on programme effectiveness.

This article examines how and why members of the public should become involved in promoting health in the community. It draws on findings from People in Public Health (South et al 2010), which investigated approaches to developing and supporting lay people in public health roles. In practice, there are different approaches and health projects that can involve people in this way. Two case studies from the UK are used to illustrate different roles: one in which older people volunteered to spread health messages in their communities and another in which lay health workers delivered a community-based obesity management intervention for young people. The justifications for lay engagement in delivering health promotion are discussed, based on the findings from expert hearings on UK practice that were conducted as part of the study. There are many types of health project that can involve people in this way.

One in four toddlers are not achieving the recommended vitamin D intake crucial for their healthy development(1, 2). This study explored parents’ acceptability of factors affecting purchasing of foods and drinks fortified with Vitamin D in children aged 0–2 years old. A total of 194 parents completed an online parent questionnaire. Focus groups and interviews were used to explore in depth perceptions of vitamin D fortification. Thirteen participants participated in the 5 focus groups, 5 completed interviews. The majority of participants were female (mothers) and of White-British ethnic background, aged between 25–40 years, with 89 % of the sample with a level 3 qualification (e.g. 2 or more A levels, NVQ level 3). Basic descriptive statistics were calculated from the questionnaire data and a thematic analysis methodology was applied to the qualitative data. The findings indicated low purchasing of vitamin D fortified foods/drinks by parents (21 % of the sample). The foods/drinks most purchased were cereal, yogurts and alternative milks. Willingness to purchase certain products fortified with vitamin D to increase their child's vitamin D was however high. After excluding formula milk, parents would be willing to buy yogurt, yogurt drinks, cereals, milk-based drinks, fruit juice and margarine. The table outlines parents’ views on the facilitators and barriers to purchasing vitamin D fortified foods and drinks. There is a potential for fortified foods to play a role in increasing the intake of vitamin D intake. Parents need quality education explaining the need to prevent vitamin D deficiency, though fortified products. Products also need to be suitable for babies and toddlers; better labelled, lower cost; with healthy options available with lower sugar and salt content, tasty, longer shelf life and better availability in local shops and supermarkets. Future research should determine if consumption of fortified foods/drinks alone rather than supplementation is sufficient to meet children's daily intake of vitamin D(3).

The literature review has been commissioned by NHS Health Scotland to review the health behaviour change models and approaches for families, children and young people to support the development and delivery of effective child healthy weight programmes. Despite the consistent recommendations from NICE and SIGN for the inclusion of behavioural components in child healthy weight programmes, there is little information on effectiveness of specific techniques and which to incorporate. The aim was therefore to provide information on which specific behavioural treatment components, behaviour change models and approaches should underpin clinical guidelines and childhood obesity treatment programmes. Secondly, in light of recommendations for programmes to be delivered by appropriately trained professionals, the review aimed to identify the skills and competencies required and resources and training available for effective delivery of the behavioural components. The outcomes of the literature review will be applied in enhancing the guidance for practitioners involved in the development and delivery of effective child healthy weight programmes; and thereby support achievement of the Scottish Government’s HEAT 3 target aimed at monitoring the attendance and completion of approved ’child healthy weight intervention programmes’. The report includes the background, aims, and objectives, sets out the scope of the review, presents a brief description of the methods and main findings. The methods and stakeholder views are then presented followed by a discussion of the implications for applying the evidence in practice and further research recommendations.

Free school meals aim to provide a “nutritional safety net” for the poorest UK children. Yet it is estimated that up to 30% of those entitled do not take up this entitlement. In Leeds approximately 6,000 children do not take the free school meals that they are entitled to. National and local targets are for 100% take up. Phase 2 of the Leeds Free School Meal Research Project aimed to develop, implement and evaluate a series of interventions to increase the uptake of free school meals. The interventions were tested in ten Leeds schools between December 2007 and October 2008. The research was undertaken by the Department of Nutrition & Dietetics within The Centre of Food Nutrition and Health at Leeds Metropolitan University on behalf of Education Leeds.

The prevalence of infant obesity is increasing, but there is a lack of evidence-based approaches to prevent obesity at this age. This study tested the acceptability and feasibility of evaluating a theory-based intervention aimed at reducing risk of obesity in infants of overweight/obese women during and after pregnancy: the Healthy and Active Parenting Programme for Early Years (HAPPY).A feasibility randomised controlled trial was conducted in Bradford, England. One hundred twenty overweight/obese pregnant women (Body Mass Index [BMI] ≥25 kg/m(2)) were recruited between 10-26 weeks gestation. Consenting women were randomly allocated to HAPPY (6 antenatal, 6 postnatal sessions: N = 59) or usual care (N = 61). Appropriate outcome measures for a full trial were explored, including: infant's length and weight, woman's BMI, physical activity and dietary intake of the women and infants. Health economic data were collected. Measurement occurred before randomisation and when the infant was aged 6 months and 12 months. Feasibility outcomes were: recruitment/attrition rates, and acceptability of: randomisation, measurement, and intervention. Intra-class correlations for infant weight were calculated. Fidelity was assessed through observations and facilitator feedback. Focus groups and semi-structured interviews explored acceptability of methods, implementation, and intervention content.Recruitment targets were met (~20 women/month) with a recruitment rate of 30 % of eligible women (120/396). There was 30 % attrition at 12 months; 66 % of recruited women failed to attend intervention sessions, but those who attended the first session were likely to continue to attend (mean 9.4/12 sessions, range 1-12). Reaction to intervention content was positive, and fidelity was high. Group clustering was minimal; an adjusted effect size of -0.25 standard deviation scores for infant weight at 12 months (95 % CI: -0.16-0.65) favouring the intervention was observed using intention to treat analyses. No adverse events were reported.The HAPPY intervention appeared feasible and acceptable to participants who attended and those delivering it, however attendance was low; adaptations to increase initial attendance are recommended. Whilst the study was not powered to detect a definitive effect, our results suggest a potential to reduce risk of infant obesity. The evidence reported provides valuable lessons to inform progression to a definitive trial.Current Controlled Trials ISRCTN56735429.

BACKGROUND: Cardiometabolic health among adult offspring of hypertensive disorders of pregnancy (HDP) is relatively unknown. We hypothesized that offspring of HDP would have abnormalities in the retinal microvasculature and cardiac structure by midadulthood. METHODS AND RESULTS: The Cardiovascular Risk in Young Finns Study included randomly selected children from 5 Finnish university cities. The mean age of participants was 40 years (range 34-49 years) at the time of retinal photography and cardiac assessment. Offspring born ≥37 weeks of gestation and appropriate for gestational age (n=1006) were included. Offspring of HDP had higher systolic blood pressure (β=4.68, P<0.001), body mass index (β=1.25, P=0.009), and waist circumference (β=0.25, P=0.042), compared with offspring of normotensive pregnancies. However, no differences in fasting glucose, insulin, lipid profile, carotid intima media thickness, or brachial artery flow-mediated dilatation were shown. Retinal arteriolar diameters were narrower (β=-0.43, P=0.009) and longer (β=32.5, P=0.023) and the arteriolar length-to-diameter ratio was higher (β=2.32, P=0.006) among offspring of HDP, after adjustment for age and sex. Left atrial volume indexed to body surface area (β=1.34, P=0.040) was increased. Adjustment for the confounding effects of birth weight, body mass index, smoking and socioeconomic status, and the mediating effect of hypertension had little impact on the associations. CONCLUSIONS: Abnormalities of the retinal microvasculature and cardiac structure are seen in offspring of HDP in midadulthood. These findings may need to be considered in future primary prevention strategies of cardiovascular disease among offspring of HDP.

Purpose: The purpose of this paper is to design and implement interventions to increase free school meal (FSM) uptake in pilot schools. This paper describes the interventions, reports on acceptability (as perceived by school working parties) and explores the process of implementing change. Design/methodology/approach: The research consisted of two phases, an exploratory phase followed by an intervention phase. Findings from the latter are presented. Ten pilot schools (five primary and five secondary) in Leeds, England were recruited. Each established a working party, examined current claiming processes and implemented individualised action plans. This paper draws on the final action plans and interviews/focus groups with working parties. Findings: Interventions to improve FSM claiming process, minimise discrimination and maximise awareness were designed. The majority were implemented successfully, the exception being amending anti-bullying policies. Creative ways of delivering interventions were demonstrated. The process of change was effective, critical factors being having individualised action plans that allowed flexibility in implementation, reflecting on current claiming processes, and setting up working parties. Practical implications: Ways of working with schools to increase FSM uptake and more generally improve nutritional policies are suggested. Amending claiming systems in schools is recommended as is greater pupil and parent involvement in nutrition policies. Originality/value: An estimated 300,000 UK children do not take FSMs they are entitled to – with many schools unaware of the issue. This study worked with schools to discover how to address this issue and evaluated the perceived acceptability and feasibility of the approach.

BACKGROUND: Vitamin D deficiency has been highlighted as a serious public health problem in the United Kingdom. One in four toddlers are not achieving the recommended intake for their healthy development. This study uses quantitative and qualitative methods to explore parents' perceptions, awareness and behaviours around vitamin D intake, and the acceptability of and factors affecting purchasing of food and drink fortified with Vitamin D in children aged 0-2 years old. METHODS: One hundred and ninety-four parents completed an online questionnaire, advertised to parents with one child aged up to 2 years on popular social media websites. The majority of participants were mothers, White-British ethnic background, aged 25-44 years. Participants provided an email address if they wanted to be contacted about the focus groups. Recruitment posters advertising the focus groups were placed in community centres. Eighteen participated in 5 focus groups (13 parents), and 5 individual interviews. A thematic analysis methodology was applied. RESULTS: Fifty-seven percent (n = 110) of parents reported receiving information about vitamin D during pregnancy and 52% (n = 100) after the birth of their child. Parents reported a low level of satisfaction with vitamin D information: many thought it was limited and recommendations on supplements were unclear. Parents wanted more information about vitamin D requirements for their child (80%, n = 153 out of 192 respondents, 2 non-response), about vitamin D and breastfeeding (56%, n = 108) and vitamin D and pregnancy (49%, n = 94). The recommendations were for simpler, easier to read, with specific and clearer guidelines; delivered regularly during routine appointments, at timely stages throughout pregnancy and after the birth. 23% (n = 45, out of 194 respondents) of parents did not know why vitamin D is important for health. Only 26% (n = 49, out of 192 respondents) of parents reported giving their youngest child a vitamin D supplement on most days of the week. The majority of parents (interview/focus group) wanted more information about foods/drinks fortified with vitamin D. CONCLUSION: Parents were generally not aware of the importance of vitamin D, dietary requirements including supplementation and the availability of vitamin D fortified foods. Major improvements are required for the effective promotion of vitamin D information to parents.

Copyright © The Authors 2015 Despite recent attempts to improve the quality of school meals in England through the introduction of school meal standards, uptake remains low. Since the introduction of the universal infant free school meal (UIFSM) scheme in September 2014 all pupils in Reception, Year 1 and Year 2 in English state-funded primary schools are eligible to receive a free lunch. This study aimed to explore the perceptions of pupils, catering managers and head teachers concerning school meal provision in eight primary schools in North England and provides a unique insight into each school’s preparation for implementation of UIFSM. A total of thirty-two focus groups were conducted with sixty-four pupils aged 7–8 years (Year 3) and sixty-four pupils aged 9–10 years (Year 5) in June–July 2014, to explore perceptions of school meals. Interviews were carried out with six catering managers and five head teachers concerning catering and the impending implementation of UIFSM. Increasing acceptance of school meals could lead to improved uptake. Pupils desired increased choice and menu variety, including greater variety of vegetables and fruit. Caterers can influence the quantity and types of foods offered to pupils, and there are opportunities for them to promote healthy eating behaviours in the dining room. The important roles of school meal providers, caterers, pupils and parents need to be recognised to improve delivery and acceptability of school meals and ultimately school meal uptake. There were practical challenges to implementation of UIFSM, with some concerns expressed over its feasibility. Head teachers were mainly positive about the potential beneficial impacts of the scheme.

One in four toddlers are not achieving the recommended vitamin D intake crucial for their healthy development(1, 2). This study explored parents’ acceptability of factors affecting purchasing of foods and drinks fortified with Vitamin D in children aged 0-2 years old. A total of 194 parents completed an online parent questionnaire. Focus groups and interviews were used to explore in depth perceptions of vitamin D fortification. Thirteen participants participated in the 5 focus groups, 5 completed interviews. The majority of participants were female (mothers) and of White-British ethnic background, aged between 25-40 years, with 89% of the sample with a level 3 qualification (e.g. 2 or more A levels, NVQ level 3). Basic descriptive statistics were calculated from the questionnaire data and a thematic analysis methodology was applied to the qualitative data. The findings indicated low purchasing of vitamin D fortified foods/drinks by parents (21% of the sample). The foods/drinks most purchased were cereal, yogurts and alternative milks. Willingness to purchase certain products fortified with vitamin D to increase their child’s vitamin D was however high. After excluding formula milk, parents would be willing to buy yogurt, yogurt drinks, cereals, milk-based drinks, fruit juice and margarine. The table outlines parents’ views on the facilitators and barriers to purchasing vitamin D fortified foods and drinks. There is a potential for fortified foods to play a role in increasing the intake of vitamin D intake. Parents need quality education explaining the need to prevent vitamin D deficiency, though fortified products. Products also need to be suitable for babies and toddlers; better labelled, lower cost; with healthy options available with lower sugar and salt content, tasty, longer shelf life and better availability in local shops and supermarkets. Future research should determine if consumption of fortified foods/drinks alone rather than supplementation is sufficient to meet children’s daily intake of vitamin D(3).

© 2019 The Author(s). Background: This study aims to evaluate the feasibility and acceptability of the PhunkyFoods Programme, a primary school-based intervention to promote healthy nutrition and physical activity knowledge and behaviours to assess outcomes to inform a phase 3 trial. Methods: The cluster randomised feasibility trial recruited eight primary schools from the North of England. Elibility criteria included all primary schools in one town, excluding independent and special schools and schools that comprised of only key stage 2 pupils (years 3-6). Eight schools agreed to participate. Randomisation to intervention or control arms was in a 1:1 ratio. Intervention schools received PhunkyFoods over 17 months. Control schools continued with usual curriculum. Assessors were blinded to group assignment. Measures comprised of a Healthy Lifestyle Knowledge Questionnaire and Synchronised Nutrition and Activity Program to assess diet and physical activity, height, weight, and psychological wellbeing. Feasibility outcomes were recruitment, attrition rates, interviews with teaching staff, focus groups with pupils to explore the acceptability of outcome measures, implementation, intervention content, and programme fidelity. Results: Three hundred fifty-eight pupils, aged 6-9 years from eight schools were recruited at baseline (control n = 170, intervention n = 188); 337 (94.1%) at 6 months (control n = 163, intervention n = 181); and 331 (92.5%) at 18 months (control n = 152, intervention n = 179), and 6 pupils opted out. Trends in increased knowledge of healthy lifestyle behaviours, healthier eating, and liking of fruit and vegetables were reported in the intervention compared to the control group. Year 4 intervention pupils had significantly higher healthy balanced diet knowledge scores compared to control pupils, mean difference 5.1 (95% CI 0.1 to 10.1, p=0.05). At 18 months, the mean percentage of vegetables liked was higher (intervention 53.9% vs. 43.0% control). Similarly, percentage of fruits liked was also higher (intervention 76.9% vs. 67.2% control). Qualitative data showed that delivery of the intervention was feasible and acceptable to teachers and pupils. Lessons were learned to inform the phase 3 trial around the dietary assessment measure and timing of recruitment. Conclusions: Whilst the study was not powered to detect a definitive effect, results suggest a potential to increase knowledge of healthy lifestyle behaviours and dietary behaviours, suggesting that with minor changes, a phase 3 trial is likely to be deliverable. Trial registration: ISRCTN, ISRCTN15641330. Registered 8 May 2015 - retrospectively registered, https://doi.org/10.1186/ISRCTN15641330

© 2019 The Author(s). Background: Primary schools are valuable settings to implement healthy lifestyle (healthy eating and physical activity) interventions, aimed at targeting childhood obesity. This study explored school staff perceptions of factors that hinder and enable successful implementation and sustainability of healthy lifestyle interventions in primary schools. Qualitative data was pooled and analysed from two evaluations carried out in primary schools in North England: a feasibility study of a nutrition and physical activity educational programme (PhunkyFoods Feasibility Study), and an evaluation of a healthy eating programme (The Food Dudes Evaluation). Methods: Sixty-five qualitative semi-structured interviews were conducted with head teachers, teachers, catering managers, designated school-based programme coordinators and programme staff supporting schools with programme delivery, at 14 schools involved in both evaluations. Thematic analysis was undertaken and emergent themes categorised using a framework for successful implementation by Durlak and Dupre (2008). Results: Overall, all schools were delivering a range of healthy lifestyle programmes, often with overlapping content. Perceived challenges to implementation of individual programmes included: limited time, timing of implementation, limited training and support, insufficient resources, capacity and facilities, staff perceptions of intervention and perceived skill-proficiency (for cooking and physical activities). Short-term funding, lack of external and internal support were perceived to hinder sustainability. Staff recommendations for successful implementation of future programmes included: extended training and planning time, sufficient capacity, external support for delivery, good resources (interactive, practical and adaptable), and facilities for cooking, healthy eating, gardening and physical activities. Head teachers need to prioritise delivery of a few key healthy lifestyle programmes, in an overcrowded curriculum. Schools need to employ strategies to engage participation of staff, pupils and parents long term. Conclusions: Effective implementation of school-based healthy lifestyle programmes was thought to be aided by flexible and adaptable programmes, enabling good contextual fit, well-resourced programmes and effective leadership at multiple levels, pupil (pupils support delivery) and parent involvement. To facilitate sustainability, it was perceived that programmes need to be integrated within the curriculum and school policies long term, with sustained support from head teachers and staff. These findings are relevant to programme developers, policy makers and those involved in delivering interventions.

Introduction: Despite clinical guidance recommending the inclusion of behavioural components in child weight management programmes, there is little evidence on the effectiveness of specific techniques and strategies. Methods: A literature review was undertaken using a series of stages based on systematic review methodology and included evidence from studies undertaken in all settings, involving children 5–18 years, parents and family. Primary outcomes of studies included weight/bmirelated measures and diet, physical activity and psychological wellbeing as secondary outcomes. The evidence summarises the results from 74 papers consisting of 12 reviews, 7 qualitative studies and 55 interventions. Results: The application of behavioural components was hindered due to a lack of standardisation in the definition of behavioural therapy (self-monitoring, stimulus control, goal-setting, use of rewards and problem-solving) and cognitive behavioural therapy (addressing faulty cognitive restructuring, self-instructional training techniques) within programmes. Behavioural components were often poorly described and not evaluated. For interventions aimed at children under 12 years it is more effective to teach behavioural techniques such as monitoring of diet and physical activity, identification of problem behaviours, goal-setting, use of praise, contracting and rewards, role modelling, positive social reinforcement and coping strategies to parents. Adolescents benefited from coping skills training and structured programmes including parental behavioural components such as coping strategies, role modelling, stimulus control and use of rewards. Conclusion: Behavioural Therapy techniques are commonly used as a ‘package’ in effective programmes however specific techniques are poorly evaluated. Few studies utilise CBT and the lack of description and evaluation prevents conclusions on effectiveness to be drawn. Conflict of interest: None. Funding: The review was funded by NHS Health Scotland.

OBJECTIVE: The present study sought to explore the factors that influence registration for free school meals and the subsequent take-up following registration in England. DESIGN: The research design consisted of two phases, a qualitative research phase followed by an intervention phase. Findings are presented from the qualitative research phase, which comprised interviews with head teachers, school administrators, parents and focus groups with pupils. SETTING: The study took place in four primary schools and four secondary schools in Leeds, UK. SUBJECTS: Participants included head teachers, school administrators, parents and pupils. RESULTS: Findings suggested that parents felt the registration process to be relatively straightforward although many secondary schools were not proactive in promoting free school meals. Quality and choice of food were regarded by both pupils and parents as significant in determining school meal choices, with stigma being less of an issue than originally anticipated. CONCLUSIONS: Schools should develop proactive approaches to promoting free school meals and attention should be given not only to the quality and availability of food, but also to the social, cultural and environmental aspects of dining. Processes to maintain pupils' anonymity should be considered to allay parents' fear of stigma.

Background/Objectives: Extensive work has addressed the validity of bioimpedance (BIA) measurements and the effect of posture on fluid homeostasis. However, limited research has investigated effects of subject preparation. This study aimed to determine the precision of total body water (TBW) and extracellular water (ECW) measurements using a stand-on multifrequency BIA (MFBIA seca mBCA 514/515), in three pre-test procedures: supine, sitting, and following walking, with specific reference to the influence of sex and BMI. Subjects/Methods: Fifty three healthy, ambulatory men (n=26, age:32.5±9.4yrs) and women (n=27, age:35.2±10.3yrs) received repeat MFBIA measurements (six measurements from 0 to 15 min). Agreement and precision were evaluated for each condition and time point. Results: Significant TBW sex differences from supine posture were observed for walking (females) and sitting (males) postures. For BMI (≤ 24.9 kg.m-2) significant TBW differences from supine were observed for both sitting and walking and significant ECW differences from sitting were also observed with both supine and walking. There was no significant effect of sex or BMI (≥ 25.0kg.m-2) on ECW measures. Irrespective of sex or BMI, there was close agreement in TBW and ECW precision over the three protocols. Conclusions: Practitioners can have confidence in the precision of TBW and ECW measurements within a 15 minute time period and pre-testing conditions (supine, sitting or walking) in healthy subjects, though must be cautious in assessments when pre-test postures change. Further research to examine the impact of pre-testing procedures on stand-on MFBIA BIA measurements, including subjects with fluid disturbance, is warranted.

With growing evidence for the positive health outcomes associated with a plant-based diet, the study’s purpose was to examine the potential of shifting adolescents’ food choices towards plant-based foods. Using a real world setting of a school canteen, a set of small changes to the choice architecture was designed and deployed in a secondary school in Yorkshire, England. Focussing on designated food items (whole fruit, fruit salad, vegetarian daily specials, and sandwiches containing salad) the changes were implemented for six weeks. Data collected on students’ food choice (218,796 transactions) enabled students’ (980 students) selections to be examined. Students’ food choice was compared for three periods: baseline (29 weeks); intervention (six weeks); and post-intervention (three weeks). Selection of designated food items significantly increased during the intervention and post-intervention periods, compared to baseline (baseline, 1.4%; intervention 3.0%; post-intervention, 2.2%) χ2(2) = 68.1, p < 0.001. Logistic regression modelling also revealed the independent effect of the intervention, with students 2.5 times as likely (p < 0.001) to select the designated food items during the intervention period, compared to baseline. The study’s results point to the influence of choice architecture within secondary school settings, and its potential role in improving adolescents’ daily food choices.

A diet dominated by plant foods, with limited amounts of refined processed foods and animal products conveys substantial health benefits. This study sought to explore adolescents’ attitudes and perceptions towards plant-based foods. Semi-structured focus group interviews were conducted with adolescents (age 14–15 years) (n = 29) attending an inner city school in Yorkshire, UK. Using a grounded theory methodology, data analysis provided four main categories and related concepts revolving around adolescents’ perspectives on plant-based foods: food choice parameters; perceived drivers and benefits of plant-based foods; environmental food cues; barriers to plant-based food choice. In the emergent grounded theory, a clear disconnect between plant-based foods and the parameters that adolescents use to make food choices, is highlighted. Further, key barriers to adolescents adopting a plant-based diet are differentiated and considered with respect to practice and policy. The analysis offers a framework to remodel and re-present plant-based foods. In this way, it is proposed that a closer connection is possible, with consequent shifts in adolescents’ dietary behaviour towards a more plant-based diet and associated health benefits.

A cohort of schoolchildren was followed up over 6 years from 1996 to 2001. In the final year, 315 of 500 targeted children were measured. Body mass index (BMI) increased substantially over time (p<0.001), indicating a further rise in obesity into the secondary school years. Two new indicators of obesity were also measured. Waist circumference scores rose as substantially as BMI (p<0.001), and may be of particular significance given the association between abdominal girth in adults and cardiovascular morbidity. International Obesity Task Force measures were found to be more stringent than previous criteria, with no significant change noted over the time period.

Background: The WATCH IT programme was developed to address the needs of obese children from disadvantaged communities in Leeds and has been running since January 2004. Results of the pilot phase, prior to a randomised controlled trial, are presented. Methods: A process evaluation to assess success of implementation was conducted in December 2004. User views (parent and child) were obtained by semi-structured interviews and focus groups. Change in BMI SD score was calculated for children attending between January 2004 and November 2005. Results: A total of 94 children (49 girls, 45 boys), mean age (SD) 12.2 (2.0) years attended. They were moderately to severely obese (mean BMI SDS 3.09 (0.45), with low quality of life and self-image scores. There was a significant reduction in overweight at 6 months (ΔBMI SD -0.07), especially for teenagers (ΔBMI SD -0.13) and girls (ΔBMI SD -0.07). The programme was successfully implemented. By December 2004 mean attendance was 2.1 (0.7) clinics per month, and sports sessions 3.3 (1.7) sessions per month. Fourteen children dropped out and non-attendance was low (only 7.5% sessions missed in 12 months). Qualitative research indicated significant appreciation of the service, with reported increase in self-confidence and friendships, and reduction in self-harm. Conclusion: WATCH IT offers a model for a community based service for obese children. The programme suggests that effective care can be delivered by health trainers supervised by health professionals, and so potentially provides a cost effective programme within children's communities. These findings are encouraging, and need to be substantiated by extension to other locations and evaluation by randomised controlled trial.

© 2019 Elsevier B.V. Local government organisations (LAs) have a major role in the prevention and treatment of obesity in England. This study aims to 1) understand what actions are being taken by LAs to address obesity, and 2) determine how actions counter the perceived causes of obesity when mapped against the Wider Determinants of Health (WDoH) model. Thirty-two LAs were invited to complete an Action Mapping Tool, 10 participated. The tool requires LAs to document actions being implemented locally to address obesity. This then enables LAs to map their actions against the perceived causes of obesity, using the WDoH model as an analytical lens. We collated data from the 10 LAs and used an adapted framework synthesis method for analysis. 280 actions were documented across the 10 LAs; almost 60% (n = 166) targeted Individual Lifestyle Factors (ILF), with 7.1% (n = 20), 16.8% (n = 47) and 16.4% (n = 46) targeting Social and Community Factors (SCF), Living and Working Conditions (LWC) and Wider Conditions (WC) respectively. Conversely, 60% of causes were spread across the LWC and WC, with 16.4% regarded as ILF. Physical activity-, weight management-, and health improvement- programmes were most frequently implemented by LAs. There is a stark mismatch between LA actions on obesity and its perceived causes. Given that LAs acknowledge the complex aetiology of obesity, an equally comprehensive approach should be implemented in the future.

Background: Increasing awareness of the complexity of public health problems, including obesity, has led to growing interest in whole systems approaches (WSAs), defined as those that consider the multifactorial drivers of overweight and obesity, involve transformative co-ordinated action across a broad range of disciplines and stakeholders, operate across all levels of governance and throughout the life course. This paper reports a systematic review of WSAs targeting obesity and other complex public health and societal issues, such as healthy lifestyles for prevention of non-communicable disease. Methods: Seven electronic databases were searched from 1995 to 2018. Studies were included if there had been an effort to implement a WSA. Study selection was conducted by one reviewer with a random 20% double checked. Data extraction and validity assessment were undertaken by one reviewer and checked by a second reviewer. Narrative synthesis was undertaken. Results: 65 articles were included; 33 about obesity. Most examined multicomponent community approaches, and there was substantial clinical and methodological heterogeneity. Nevertheless, a range of positive health outcomes were reported, with some evidence of whole systems thinking. Positive effects were seen on health behaviours, body mass index (BMI), parental and community awareness, community capacity building, nutrition and physical activity environments, underage drinking behaviour and health, safety and wellbeing of community members, self-efficacy, smoking and tobacco-related disease outcomes. Features of successful approaches reported in process evaluations included: full engagement of relevant partners and community; time to build relationships, trust and capacity; good governance; embedding within a broader policy context; local evaluation; finance. Conclusions: Systems approaches to tackle obesity can have some benefit, but evidence of how to operationalise a WSA to address public health problems is still in its infancy. Future research should: (a) develop an agreed definition of a WSA in relation to obesity, (b) look across multiple sectors to ensure consistency of language and definition, (c) include detailed descriptions of the approaches, and (d) include process and economic evaluations.